At the end of 2003, an estimated 1 million people were living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) in the USA.^w1 Since the advent of highly active antiretroviral therapy (HAART) in 1996, HIV related mortality has decreased dramatically.^w2 However, as patients are living longer, chronic health complications such as cardiovascular disease represent an increasing important health issue in this patient population. The aetiology of cardiovascular disease in HIV infection is not well established, and may be related to viral infection itself, the use of HAART, or altered immune responses. This review will focus on cardiovascular manifestations of HIV infection, with particular emphasis on coronary heart disease (CHD) and cardiovascular risk factors.

HIV AND CORONARY HEART DISEASE

Epidemiology

The first case reports of acute myocardial infarction (MI) in HIV infected patients on HAART were described in 1998.^{w3 w4} Since then, it has become increasingly clear that individuals with HIV infection are at high risk for cardiovascular events. The relative contributions of HIV infection versus potential adverse effects of HAART to CHD risk, however, remain unclear. Although the data from numerous studies on coronary events in HIV disease are conflicting (table 1), the majority of studies suggest that antiretroviral therapy increases CHD risk in HIV patients.

The largest study showing no effect of HIV or HAART use on cardiovascular risk is the Veterans Affairs study, which showed no significant increase in cardiovascular or cerebrovascular events in patients treated with HAART or protease inhibitors (PIs) compared with age adjusted US population rates.1 In contrast, the largest study showing an increased incidence rate of MI was the French Hospital Database, where rates of MI were particularly increased in subjects with long term exposure to PIs.^w5 Similarly, the Data Collection on Adverse Effects of Anti-HIV Drugs (DAD) study showed an increased incidence …